021517 DUPLICATE WARRANTS 3_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: January 23, 2017
Re: Replacement of Lost Payroll Warrants
Please find attached 2 Affidavit/Notice of Claim(s) for lost
payroll warrants for inclusion on the next available Board agenda.
The attached item(s) have been researched to ensure that the
warrant(s) in question have not been cashed or previously re-
issued. The original warrant(s) have had a stop payment done.
Please call Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: gl Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Orville J Waters (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/30/2016 (date)( 2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
warrant/check be issued to him/her in the sum of $ 140.00 .(3)
Signed: (4)
Note: Please atigteh a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and worn to before me this / `e l day of Jaot-ta-i- y 20 17 .
pie" 7/..-t4.1,4A-Th
NOTARY PUBLIC
BERTA RAMIREZ
My commission expires: Notary Pubk•State of Afilal
A- ay 7 , 2c3 *Commission MAR1COPA Expires COUNTY May 7, 2018 (seal)
Warrant/Check Number 22439742
(if known) (61
Original Date of Issue 11/30/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
RI Payroll
ID For Services or Goods furnished
CI Treasurer's refund/payment
El Other:
Revised April 2015 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
John Michael Miller (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about November 30, 2016 (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
warrant/check be issued to hi, c he rVhe sikn\ofjp_190.00 .(3)
S igned: \1 (4)
Note: Please attach a copy of the warrant/chek if available and/or any other
evidence that a warrant/check was originally is ed,
(5) Subscribed and sworn to before me this day of /6/4/6(-1(--(411 20
24 / 74i-)2 // e 6
NOTARY PUBLIC
DIMITRINKA TRIFONOVA
My , . commission expires: Th e,z2c, STATE NOTARY OF COLORADO PUBLIC
MYCOMMISSION NOTARY ETIRES ID 20164030990 OCTOBER 112,41110213,'
Warrant/Check Number 22438716
(if known) (6)
Original Date of Issue 11/30/2016
(if known) (7)
••I•
Reason for original issue of Warrant/Check (8):
Payroll ZIM
El For Services or Goods furnished
0 Treasurer's refund/payment
0 Other: -CLERK, MARICOPA BOARD OF COUNTY SUPERVISORS r-r-7
Revised April 2015 A.R.S. 11-632 & 11-644